Association of center volume with outcomes in critically ill children with acute asthma

Changes in Pediatric ICU Utilization and Clinical Trends During the Coronavirus Pandemic

BACKGROUND

Children have been less affected by the COVID-19 pandemic, but its repercussions on pediatric illnesses may have been significant. This study examines the indirect impact of the pandemic on a population of critically ill children in the United States.

RESEARCH QUESTION

Were there significantly fewer critically ill children admitted to PICUs during the second quarter of 2020, and were there significant changes in the types of diseases admitted?

STUDY DESIGN AND METHODS

This retrospective observational cohort study used the Virtual Pediatric Systems database. Participants were 160,295 children admitted to the PICU at 77 sites in the United States during quarters 1 (Q1) and 2 (Q2) of 2017 to 2019 (pre-COVID-19) and 2020 (COVID-19).

RESULTS

The average number of admissions was similar between pre-COVID-19 Q1 and COVID-19 Q1 but decreased by 32% from pre-COVID-19 Q2 to COVID-19 Q2 (20,157 to 13,627 admissions per quarter). The largest decreases were in respiratory conditions, including asthma (1,327 subjects in pre-COVID-19 Q2 (6.6% of patients) vs 241 subjects in COVID-19 Q2 (1.8%; P < .001) and bronchiolitis (1,299 [6.5%] vs 121 [0.9%]; P < .001). The percentage of trauma admissions increased, although the raw number of trauma admissions decreased. Admissions for diabetes mellitus and poisoning/ingestion also increased. In the multivariable model, illness severity-adjusted odds of ICU mortality for PICU patients during COVID-19 Q2 increased compared with pre-COVID-19 Q2 (OR, 1.165; 95% CI, 1.00-1.357; P = .049).

INTERPRETATION

Pediatric critical illness admissions decreased substantially during the second quarter of 2020, with significant changes in the types of diseases seen in PICUs in the United States. There was an increase in mortality in children admitted to the PICU during this period.

Cross-sectional Survey of Canadian Pediatric Critical Care Transport

OBJECTIVES

This study aimed to better understand the unique aspects of pediatric critical care transport programs across Canada by characterizing the current workforce of each transport program.

METHODS

A cross-sectional questionnaire was sent to the 13 medical directors of Canada's pediatric critical care transport teams, and to 2 nonhospital-affiliated transport services. If a children's hospital did not have a dedicated team for pediatric transport, the regional transport team providing this service was identified.

RESULTS

Eight of the 13 pediatric intensive care units surveyed have unit-based pediatric transport teams. The median annual transport volume for the 8 hospital-based teams was 371 (range, 45-2300) with a total of 5686 patients being transported annually. Among patients transported by the 8 teams, 45% (2579 patients) were pediatric patients (older than 28 days and younger than 18 years) and 40% (1022 patients) of the pediatric patients were admitted to the pediatric intensive care units. Eighty-eight percent of the responding teams also transported neonates (older than 28 days), and 38% transported premature infants.A team composition of registered nurse-respiratory therapist-physician was used by 6/13 teams (75%); however, it accounted for only a small proportion of the transports for most of the teams (median, 2%; range, 2%-100%).The average transport time from dispatch (from team home site) to arrival at receiving facility was reported by 6 teams, and has a median of 195 minutes (range, 90-360 minutes). The median distance from home site to the farthest referral site in the catchment area was 700 km (range, 15-2500 km).

CONCLUSIONS

This is the first Canadian nationwide study of pediatric critical care transport programs. It revealed a complexity and variability in transport team demographics, transport volume, team composition, and decision-making process.

Pediatric Triage in a Severe Pandemic: Maximizing Survival by Establishing Triage Thresholds

OBJECTIVES

To develop and validate an algorithm to guide selection of patients for pediatric critical care admission during a severe pandemic when Crisis Standards of Care are implemented.

DESIGN

Retrospective observational study using secondary data.

PATIENTS

Children admitted to VPS-participating PICUs between 2009-2012.

INTERVENTIONS

A total of 111,174 randomly selected nonelective cases from the Virtual PICU Systems database were used to estimate each patient's probability of death and duration of ventilation employing previously derived predictive equations. Using real and projected statistics for the State of Ohio as an example, triage thresholds were established for casualty volumes ranging from 5,000 to 10,000 for a modeled pandemic with peak duration of 6 weeks and 280 pediatric intensive care beds. The goal was to simultaneously maximize casualty survival and bed occupancy. Discrete Event Simulation was used to determine triage thresholds for probability of death and duration of ventilation as a function of casualty volume and the total number of available beds. Simulation was employed to compare survival between the proposed triage algorithm and a first come first served distribution of scarce resources.

MEASUREMENTS AND MAIN RESULTS

Population survival was greater using the triage thresholds compared with a first come first served strategy. In this model, for five, six, seven, eight, and 10 thousand casualties, the triage algorithm increased the number of lives saved by 284, 386, 547, 746, and 1,089, respectively, compared with first come first served (all p < 0.001).

CONCLUSIONS

Use of triage thresholds based on probability of death and duration of mechanical ventilation determined from actual critically ill children's data demonstrated superior population survival during a simulated overwhelming pandemic.

Pediatric Intensive Care Databases for Quality Improvement

The availability and breadth of collected data has grown exponentially in pediatric critical care medicine. This growth is driven by the practitioners' desire to understand and improve practice. In this manuscript, the author details the registry design factors that must be considered to meet quality improvement and safety needs in pediatric critical care units. The challenges to maintain a high standard database and data on health care delivery performances using the VPS registry data are provided.

Burn center volume makes a difference for burned children

OBJECTIVES

Determine the relationship between the volume of burn admissions and outcomes for children with burns.

DESIGN

Retrospective review of the National Burn Repository from 2000-2009 using mixed effect logistic regression modeling.

SETTING

Tertiary burn centers in the United States.

PATIENTS

All children <18 years of age admitted with burn injury to a burn center submitting data to the National Burn Repository.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of the 210,683 records in the NBR from 2000-2009, 33,115 records for children ≤ 18 years of age met criteria for analysis; 26,280 had burn sizes smaller than 10%; only 32 of these children died. Volume of children treated varied greatly among facilities. Age, total body surface area burn, inhalation injury, and burn center volume influenced mortality (p < 0.05) An increase in the median yearly admissions of 100 decreased the odds of mortality by approximately 40%. High volume centers (admitting >200 pediatric patients/year) had the lowest mortality when adjusting for age and injury characteristics (p < 0.05).

CONCLUSIONS

Higher volume pediatric burn centers had lower mortality, particularly at larger burn sizes. The lower mortality of children a high volume centers could reflect greater experience, resource, and specialized expertise in treating pediatric patients.